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Improper endotracheal tube placement

by Olga Maystruk, Designer and Brand Strategist, and
Susie Edwards, Senior Risk Management Specialist


In early September, a 34-year-old man was brought to the emergency department (ED) by EMS. The patient had shortness of breath and his blood pressure was 218/129 mm Hg. The patient had prescriptions for four hypertension medications; however, he reported that he only took one of them.

Physician action

The patient was admitted to the ICU by a hospitalist. A chest x-ray and a CT scan ruled out pulmonary embolism but indicated pneumonia. The hospitalist diagnosed the patient with malignant hypertension and ordered further testing to rule out systemic scleroderma renal crisis. 

The hospitalist also ordered a nephrology consult. The nephrologist noted the patient had been admitted to the ED seven months earlier with renal failure and was treated with dialysis. The patient’s dialysis treatments were stopped in June due to a lack of insurance. 

The patient was given hypertension medication in the ICU. After his blood pressure improved, he was moved from the ICU to the floor on his second night in the hospital.

The next morning, the patient reported difficulty breathing when lying down. The nurse noted bilateral radial and pedal pulses being "thready, weak, difficult to palpate." The hospitalist ordered an echocardiogram and a chest CT to evaluate the progress of the patient’s scleroderma. The scans showed severe left ventricular hypertrophy with abnormal diastolic function and hypertensive cardiomyopathy. 

The patient’s medical record included a note about swallowing issues for the past five years. A swallowing test showed the patient was able to swallow thin liquids easily, but he had "increased work of breathing" when given solids. Following testing, the nurse noted that the patient was anxious, thrashing around in his bed, and had increased difficulty breathing. 

The hospitalist was paged STAT and rapid response was called. The patient was given morphine. An electrocardiogram showed possible left atrial enlargement, right axis deviation, and a possible anterior infarct of undetermined age. 

A full code was called, and the hospitalist intubated the patient. The staff confirmed intubation with CO2 detector and auscultation of the lungs. A chest x-ray taken 12 minutes after intubation showed questionable position of the endotracheal tube. The tube was removed and an anesthesiologist reintubated the patient. However, the patient had suffered an anoxic brain injury and never recovered. 

The patient’s family agreed to extubate him and allow for transition to comfort care. He was transferred to hospice care and died two days later.


A lawsuit was filed against the hospitalist and the hospital alleging improper intubation resulting in anoxic brain injury and death.

Legal implications

Expert consultants who reviewed the case for the defense were mostly supportive of the hospitalist’s care of the patient. There was agreement that the rapid response; immediate intubation following proper sedation of the patient; use of the CO2 detector and auscultation of the lungs; and subsequent recognition of loss of the airway with rapid reintubation were all conducted within the standard of care. However, there was concern that it was impossible to tell from the angles of the chest x-rays after the intubation whether the tube was in the esophagus or the trachea. 

One consultant expressed concern that the hospitalist and/or the ED staff would give a sedative (morphine) to a patient whose lungs were filling with fluid. This same consultant added that while the hospitalist appeared to appropriately intubate the patient, documentation suggested that the endotracheal tube may have been pulled back too far and slipped out of the trachea during its repositioning. Again, the patient’s x-ray did not show clearly whether the tube was in the esophagus or the trachea. 

Another consultant for the defense noted the severity of the patient’s condition before intubation typically results in a poor prognosis. 


The case was settled on behalf of the hospitalist. The outcome of the case against the hospital is unknown.

Risk management considerations

Proper endotracheal tube placement in all patients should be confirmed at the time of initial intubation. The American College of Emergency Physicians describes appropriate confirmation as consisting of physical examinations and monitoring equipment including: 

  • auscultation of the chest and epigastrium;
  • visualization of thoracic movement;
  • fogging in the tube;
  • pulse oximetry;
  • chest radiography;
  • direct visualization of the endotracheal tube passing through the vocal cords into the trachea;
  • use of end-tidal carbon dioxide detector; and
  • additional methods that might include esophageal detector device, ultrasound, or bronchoscopy.(1) 

The hospitalist maintained that all proper steps were taken to confirm the placement of the ETT. However, documentation in the medical record was incomplete and unable to fully support this statement. 

An additional documentation issue included conflicting times entered in the patient’s chart, causing confusion as to exactly when actions were taken. For example, it was not clear when the radiology report was interpreted/read by the hospitalist. 

It is important that when physicians review diagnostic results that they document that the results have been reviewed and when they were read, as well as any additional treatment or testing that may be required as a result. 

Also, the time of the hospitalist’s intubation was not documented, but the time of the anesthesiologist’s intubation was included in the patient record. An addendum by another defendant was discovered to have been entered months after the patient’s death.

Defense counsel confirmed the medical record documentation was a considerable weakness in this case. In the event of a claim, thorough documentation of what was done during treatment offers a much better defense than relying on what a physician says he or she does routinely.

The medical records should be amended within a reasonable amount of time that would allow the provider to recall the specific details of the patient encounter. (2) According to the Texas Administrative Code, each licensed physician “shall maintain an adequate medical record for each patient that is complete, contemporaneous and legible.” The code also instructs that any amendment, change, or correction in a medical record “not made contemporaneously” must be noted by clearly indicating an amendment or change has been made along with the time and date. (3)

When creating an addendum to a patient record it is important to include:

  • the date of the amendment;
  • reasons for making the addendum;
  • clear notation that the added information is an addendum; and
  • the signature of the physician.

Physicians outside of Texas should refer to their state regulations on medical records.


  1. Verification of Endotracheal Tube Placement. Policy statements. American College of Emergency Physicians. Reaffirmed January 2022. Available at Accessed September 13, 2022.
  2. Pelaia RA. Medical Record Entries: What is Timely and Reasonable? American Academy of Professional Coders. September 1, 2013. Available at Accessed September 13, 2022. 
  3. Texas Administrative Code. Title 22, Part 9. Chapter 165. Medical Records. Rule 165.1(a) 11. Amended to be effective November 10, 2019. Available at$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1. Accessed September 13, 2022.

Olga Maystruk can be reached at

Susie Edwards can be reached at